Reflux/coughing associated with RNY Gastric Bypass

Question
QUESTION: I am a 58 year old female who had RNY Gastric bypass in 2003.  I lost 145 pounds, but regained about 50.  I have had complications with perforated ulcers (twice) and bleeding ulcers (once).  A gastrogastric fistula from the first ulcer was found to be the causative culprit and was finally repaired (along with a vagotomy)in Aug. 2007.  In  April 2008, the coughing began.  It escalated through the summer and I was seen by pulmonologist, allergists, and gastroenterologist.  I had chest Xrays, sinus X-rays, upper GI, and multiple allergy tests all to no avail.  The specialist threw their hands up in despair as I was coughing 24/7 (even unable to hold conversation with my doctors!) and then I went to a bariatric surgeon (my own had retired) because I had an incarcerated hernia (I had managed to reduce it on my own, but saw him one week later.)  He felt that it was reasonable to believe the hernia was causing reflux and therefore the cough. (although I had had testing for reflux).  The surgery was done, the coughing improved (did not disappear),  but within a month or so was back.  It escalated through Jan.  and I finally went to my PC who diagnosed pneumonia.  I have completed 10 days of Avelox, but the cough persists.  I had a chest Xray two days ago; it was normal.  I do have a bulge that MAY (according to my PC) be another hernia but it has not broken through the wall.  My question is this:  as a post bariatric surgical patient, it is possible that reflux through my pouch is the causative factor and if so, what kind of testing should be done to determine that?  I am so very tired of coughing.  Please help!

ANSWER: Wow Pat, this is a really tough problem.

First, let me say that it DOES seem quite possible that the source of your coughing and pneumonia is reflux and aspiration of small amounts of fluid from your stomach.  I say this in the assumption that the other doctors (especially the pulmonologist) have made a good try at diagnosing a problem coming directly from your respiratory system.  My remaining comments have to do with:
-how can reflux aspiration be confirmed
-where might it come from
-how to treat it

You wrote that you had testing for reflux, and I perceive this was negative/normal.  The thing is that even tiny amounts of harsh/irritating digestive juice can cause problems if it gets into your sensitive lungs.  Rather than have you tell me about all the tests that have been done, I suggest for you to go back to the gastro-enterologist and ask him/her to help look for ANY acid or bile reflux.  You may also benefit from having an ENT doctor do a scope to look at your larynx and vocal cords - if these are inflamed it is a pretty sure bet that aspiration is the cause.

You can have lung-damaging reflux that is composed of acid, or of digestive juice that comes from deeper down in your digestive tract - bile and pancreatic juice.  These juices are normally present, and the medical problem is that they are (maybe) washing backwards up your esophagus instead of traveling downstream.  The first abnormality is probably that you have a weak valve at the top of your stomach (called the Lower Esophageal Sphincter), and this is probably further weakened by a Hiatal Hernia.  (I have in mind that you will Google some of these terms for further info if you need to.)  The GI doctor can help determine if these problems are present.  The second abnormality that MAY be present is a recurrent fistula.  This may be a surprise to you, but there is a fairly high rate of fistula recurrence and if one is present that would be a "shortcut" for digestive juices from your bypassed stomach to your espophagus.  This possibility can be tested by CT scan or Upper GI X-ray, with CT being more helpful in most cases.  The third abnormality that may be present (and probably is present) is slow motility of your Roux limb and small intestine.  Based on your earlier experience with the hernia, it sounds to me like there is a good chance of some kink or twist of your intestine that is making it hard for fluids to pass downstream as they should - fluids back up and end up in your esophagus.  This kinking or twisting (technically called a partial small bowel obstruction) may be caused by a recurrent hernia or may be related to scar tissue deeper inside your abdomen.  CT scan is useful to fill in this information as well.

Treatment is guided by the findings of tests, but here are some possibilities:
-acid blocking medicine such as Nexium (my bet is that you are already on this)
-medicine to help your intestine move better, called Reglan (pretty good chance you are already on this, and it would only help if there is NOT a partial bowel obstruction)
-Questran, which is a powder that soaks up excess bile.  It might be useful to take this just before bed since most people aspirate while laying down at night
-sleep in a tilted position with the head higher than feet (called reverse Trendelenburg position, this is different than propping up your head on pillows).  This should get gravity to help keep the stuff down where it belongs
-Don't eat or drink within 2 hours of bed.  No chocolate, tobacco, alcohol.

Surgical possibilities - only to be chosen if an experienced surgeon believes they may be helpful:
-Hiatal Hernia repair
-abdominal exploration for PSBO
-repair of ventral hernia
-move the jejuno-jejunal anastomosis downstream, so that digestive juices have a harder time getting back to the esophagus
-fistula repair, if recurrent fistula

As I look back at this reply, I find that it has necessarily become rather technical.  You may wish to take this to your primary MD to see if this gives him/her any additional ideas on how to help get your lungs in better shape.

Best wishes,
Dr JP

---------- FOLLOW-UP ----------

QUESTION: Thank you so much for your helpful input.  I am planning to copy and take this to my gastroenterologist, whom I now have an appointment to see in one week.  To respond to some of your points:

The pulmonologist thought it was severe asthma, but even after prednisone, two inhalers, and two types of nebulizer treatments, he literally threw his hands up and said he just didn't know how to help me.

I am planning to go back to the Gastro doctor and request a scoping.  Can he do the larynx and cords while scoping the pouch also?  I was thinking this might reveal, if it exists, another fistula.  By the way, the first fistula was between my pouch and my stomach, allowing the acid to wash into the pouch.

At the time the fistula was repaired, a small hiatal hernia was also found and repaired.

I did not mention a couple of other symptoms I am experiencing.  I have recurring hives (this has been going on for over a month) on my legs, buttocks, and under my armpits.  I take Xyzal and they disappear for 24 hours only to return again.  While on the antibiotic for the pneumonia, I had no hives.  A week or so after stopping, they have returned.  Additionally, I have had prolonged and unexplained bouts of diarrhea.  The first lasted the entire month of June and half of July (a full six weeks) of extreme loose stools and gas.  My gastro doc thought it was traveller's diarrhea and gave me appropriate medication.  It didn't help so I decided to wait it out.  With time, it subsided.  However, I have had had at least four more spells of it, although not as severe.  Lasting perhaps a week or two and consisting of frequent loose (cow patty style) movements.  Again, it goes away with time.  Could this be indicative of bowl twisting?  Or is it contraindicated?

I currently take Prevacid twice a day along with Januvia (I am diabetic) and Misoprosotol.  I have stopped all other meds or OTC supplements trying to weed out the problems.  I have had extensive blood work done and all my vitamins, iron, B12 etc are normal,the only out of range is by H1C at 6.7.  I am not on Reglan, nor have I ever been other than during hospital stays.  Never had taken Questran.  My husband is going to elevate the head of our bed.  And I have stopped drinking Diet Coke and eating any chocolate.  Tobacco and alcohol have never been in the picture.

As I stated earlier, I am seeing my gastro doctor in a week. In your opinion, should I be seeing my bariatric surgeon as well, or wait and see?

Thank you so much for your help and expertise.  I truly do appreciate it.

Pat

Answer
Pat,
Seeing the gastro doc and having a scope done both seem like good ideas.  In theory, the GI do can look at your larynx and vocal cords while he is doing the scope, but in practice most GI docs are not familiar with this area and an ENT doc might still be helpful.

I would suggest that you go ahead and set up an appointment to see your surgeon, sometime about a week after your scope so that the results will be available for him/her.

As far as your loose bowels, there is a syndrome called bacterial overgrowth, which might be partially treated by the antibiotic commonly used for pneumonia or for traveler's diarrhea - if it has not already been tried your GI doc might consider Flagyl for this issue.

Best of luck,
Dr JP

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